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Attachment style, emotional control, and breast cancer.

Research in emotional control and interpersonal relations and health suggest possible linkages between attachment theory and cancer. The suppression of negative emotions, characteristic of avoidant attachment, is considered to be the core of the Type C pattern. Women with breast cancer (n=52) and without cancer (n=52) were assessed regarding attachment style and emotional control. It was hypothesized that the cancer group would score significantly higher on avoidant attachment and emotional control than the comparison group. Results supported both hypotheses. These findings are to be interpreted with caution because they are preliminary. More research is needed to determine the role of attachment as a psychosocial factor in cancer.

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Research in emotional control and interpersonal relations suggests possible links between attachment processes and cancer (Kennedy, Kiecolt-Glaser & Glaser, 1988; Temoshok & Dreher, 1992; Watson, Greet, Rowden, & Gorman, 1991). A behavior pattern for cancer--Type C--was coined independently by two researchers in the 1980s (Wood, 1985). Specifically, the Type C individual is hypothesized to be overly cooperative and appeasing, compliant with authorities, unassertive with self-sacrificing behaviors, avoidant of conflict, and unexpressive of negative emotions, especially anger (Temoshok & Dreher, 1992). This is in contrast to the hostile and aggressive Type A pattern for heart disease. The suppression of negative emotions is considered the core of the Type C pattern; studies indicate a relation between emotional suppression and breast cancer (e.g.; Watson et al., 1991). Intimate relations and affect regulation are consistent with an attachment approach. What is lacking is a theoretical framework that can integrate these areas into a coherent venue. We will explore psychosocial factors in cancer from the vantage point of attachment theory.

ATTACHMENT THEORY

Styles and Health

Bowlby (1988) proposed an attachment system that regulates the human sense of safety and protection (see Cassidy & Shaver, 1999). Attachment is conceptualized as a behavioral control system rooted in neurophysiological processes; the attachment system functions to maintain proximity to an attachment figure, usually a parent (Bowlby, 1988). The premise that early experiences lead to different attachment styles has been supported by research. The most common classification is of a secure style and two insecure styles: ambivalent and avoidant patterns (Ainsworth, Blehar, Waters, & Wall, 1978). The position that these styles involve particular affect patterns has led to attachment to be viewed as a theory of affect regulation (Kobak & Sceery, 1988).

Research indicates that children of sensitive/responsive caregivers develop a secure style (Feeney, 1999). Children whose caregivers are inconsistent tend to develop an insecure ambivalent attachment style (Hazan & Shaver, 1987). Lastly, children whose caregivers are emotionally cold and rejecting develop the avoidant style. A salient aspect of this style is high emotional control with the "masking" of negative affect--especially of anger (Kotler, Buzwell, Romeo, & Bowland, 1994). The avoidant style with its high emotional control may be a risk factor for physical health. Kotler et a1.(1994) found that avoidant individuals were more likely to exhibit higher emotional control and emotion-focused coping which was related to reports of illness.

PSYCHOSOCIAL FACTORS AND CANCER

Two areas suggest possible linkages between factors consistent with attachment theory and cancer: emotional control, and interpersonal relations and immune function.

Emotional Control

The first area of research is emotional control. As stated previously, individuals classified as exhibiting Type C behaviors are characterized by the suppression of negative emotions, particularly anger (Baltrusch, Stangel & Titze, 1991). Studies have indicated a relation between emotional suppression (a behavioral pattern of extreme suppression or control) and breast cancer (Mehrotra & Mrinal, 1996; Watson, Greer, Rowden & Gorman, 1991). Additionally, several researchers have noted the similarity of emotional control in avoidantly attached individuals and cancer patients (e.g., Kotler et al., 1994).

Interpersonal Relations and Immune Function

Research suggests that intimate relations may impact immune function. For example, investigation of immune function following disruption of attachment (marital separation) found that divorced women had significantly lower immune measures than matched controls (Kennedy, Kiecolt-Glaser & Glaser, 1988). These researchers contend that the association between close relations and immune function is "one of the most robust psychoneuroimmunological findings" (Kiecolt-Glaser & Glaser, 1992). To date, no study has examined breast cancer within an attachment framework. Thus, this pilot study hypothesized that women diagnosed with breast cancer compared to women without cancer would score higher on avoidant attachment and emotional control.

METHOD

Sample and Procedures

Participants were 104 women in a Southwestern community of approximately 200,000; 52 in the cancer group and 52 in the non-cancer group. The age range was 35 to 55, with a mean age of 47 years (SD = 5.8). Individuals in this study were primarily white upper middle class; Caucasian (93%), Protestant religious affiliation (66%), married (76%), and a modal family income of $50,000 or more (44%). In terms of education, 45% of the sample had bachelor's and graduate degrees, and 55% worked full-time (Table 1). Individuals diagnosed with cancer within the past six months or presently undergoing treatment were excluded in order to minimize the initial effects of stress of diagnosis and treatment on responses. The criteria for individuals in the non-cancer group was a health history completely clear of any suspicion of cancer, such as undiagnosed lesions, suspicious pap smears, etc.

The majority of cancer individuals (76.9%) had been diagnosed between one to six years prior to the study; the remainder (23.1%) had been diagnosed eight to fifteen years prior. To their knowledge, all of the women with a history of cancer were currently asymptomatic and disease-free. In actuality, this group consists of women in various phases of cancer survivorship. While the date of diagnosis and treatment type they received was obtained, the date they ended treatment was not. Almost half of the cancer group (48%) reported receiving combined treatments of surgery and chemotherapy and 17% reported a combination of surgery, chemo-therapy, and radiation treatments. The remainder reported one or some other combination of the above types of treatments.

Following appropriate Human Subjects approval, women with and without breast cancer were recruited to participate in a health study. Each potential participant was read a script. Specifically, they were told that the study was going to explore social and emotional factors in disease, in this case, cancer; so, they would answer questions, for example, about personal relations. The type of participation as well as the time involved was explained, as was the consent form. Following verbal agreement, the packet was mail that included questionnaires and a consent form. A mammography center and 23 local physicians' offices (i.e., oncologists, obstetricians, gynecologists) agreed to post fliers and the local newspaper advertised a request for participants. Lastly, the two nearby divisions of the American Cancer Society (ACS) invited breast cancer patients to participate in the study. The ACS offices then mailed questionnaire packets and also collected the completed questionnaires.

Women who responded through the primary investigator were mailed consent forms and assured of confidentiality and anonymity. Once consent forms were received, questionnaire packets were then sent with self-addressed, stamped return envelopes and paid postage. All recruitment procedures were used simultaneously. The entire sample was obtained in a short period of time (3 months). Of the 126 individuals who responded, 104 women (82%) actually completed the instruments for this study.

MEASURES

The questionnaire packet mailed included demographics, information on family of origin history of cancer, and a lifelong health history. Individuals who specified breast cancer proceeded to answer questions about that experience: age at diagnosis, date of diagnosis, and the types of treatment they received. The health history specifically addressed physical disorders; past or present psychological difficulties or current life stressors were not assessed. Physical symptoms such as fatigue were not specifically stated, however an open-ended item was included where participants could add information not listed but which they felt was pertinent.

Attachment Styles

The Adult Attachment Questionnaire (AAQ) is a 17-item measure that asks individuals to indicate how they relate to romantic partners "in general," thereby attempting to tap into generalized attachment attitudes, behaviors, and experiences (Simpson, Rholes, & Phillips, 1996). If individuals did not currently have a partner, they were instructed to relate questions to their most recent partner. This approach is in line with Hazan and Shaver's (1987) approach, which contributed the prototype adult attachment measure from which later measures have been derived. Attachment may be assessed by present or past relationships since it is believed that what is being assessed are relatively stable, mental representations of attachment figures. Each item is answered on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). The AAQ consists of two dimensions: avoidance and ambivalence in relations (Simpson et al., 1996). High scores on the avoidant or ambivalent scales indicate greater respective tendencies, while low scores on both indicate a secure orientation. Research has provided evidence for construct and discriminant validity (Simpson et al., 1992).

Emotional Control

To measure control of emotional expression, the Courtauld Emotional Control Scale (CECS) was used (Watson & Greer, 1983). This is a 21-item instrument designed to measure degree of control to feelings of anger, sadness, and anxiety. Responses are rated on a 4-point scale ranging from "almost never" to "almost always." The total CECS score is used as a measure of overall emotional control; a high score indicates greater control of emotion as reflected by the total score. The CECS has acceptable reliability and concurrent and discriminant validity (Watson et al., 1983).

RESULTS

The hypotheses were tested using a basic One Way Analysis of Variance (ANOVA) model with cancer/no cancer as the grouping variable and avoidant attachment and emotional control (total control scale) as the dependent variables. In addition to hypotheses testing, ANOVAs and Chi Square analyses were conducted as part of the preliminary analysis in order to identify possible covariates.

Preliminary Analysis

To identify potential categorical covariates, Chi square analyses were conducted with cancer group status and religion, ethnicity, marital and work status, education, and family of origin variable of family history of cancer. See Table 1 for demographics by group. Family history of cancer [X.sup.2] (1, N=104) = 4.96, p <.05) and work status [X.sup.2] (2, N=104) = 8.74, p <.01) were significantly related to group status. Thus, women with breast cancer were more likely to come from families who had experienced the disease (73%) than women without cancer (52%). Women with cancer also were more likely to be less employed. This finding among the cancer group may be possibly related to or a consequence of their disease experience. For group differences in the continuous demographic variable of age, an ANOVA was conducted. Women with cancer were older (M = 48.28; SD = 5.16) than women without cancer (M = 45.75; SD = 6.14); F (1, 102) = 4.90, p < .05. None of the demographic variables were related to any of the dependent variables (see Table 2 for means and standard deviations). Consequently, we decided to use family history as a covariate in subsequent analyses.

Last, we ran correlations among the dependent variables to determine if relations among the avoidant style and emotional control were consistent with attachment theory. Women who scored high on avoidance also scored higher on emotional control; thus, avoidant attachment was significantly related to emotional control (r = .34, p <.01). This finding is consistent with an attachment framework. Based on preliminary findings, hypotheses 1-3 were tested by One Way Analysis of Covariance (ANCOVA) with group (cancer/no cancer) as the independent variable and attachment style (AAQ) and emotional control (CECS) as the dependent variables, with family history of cancer as the covariate.

Avoidant Attachment

Hypothesis I was supported. There was a significant main effect for cancer group for avoidant attachment, F(1,102) = 9.15, p <.01. The cancer group (M = 32.71, SD = 9.9) reported significantly higher avoidance than the non-cancer group (M = 27.00; SD = 9.34).

Emotional Control

Hypothesis 2 was supported. Women with breast cancer reported a significantly higher degree of emotional control (M = 57.63; SD = 11.66) than did women without breast cancer (M = 44.98; SD = 10.93), F(1,102) = 32.57, p< .001.

DISCUSSION

Interest into the role of psychosocial factors in cancer has increased, as shown by recent meta-analyses which indicated a modest association between psychosocial variables and breast cancer (McKenna, Zevon, Corn, & Round, 1999). Consistent with the hypotheses, women in the cancer group scored significantly higher than did the comparison group on avoidant attachment and emotional control. The control of negative emotions is considered the core characteristic of the Type C pattern of individuals with cancer (Baltrusch et al., 1991). While these findings are consistent with avoidant attachment, they are prehminary and should be interpreted with caution. They do not indicate a causal relationship between the avoidant attachment style and breast cancer.

It is likely that the trauma of receiving the breast cancer diagnosis and going through the treatment invokes avoidance as a coping mechanism. Behavioral and cognitive avoidance have been found to be associated with emotional distress in breast cancer patients (Carver et al., 1993). Avoidant responses also are salient to posttraumatic stress disorder (PTSD): research indicates that individuals who are diagnosed with breast cancer may be at risk for PTSD symptoms (Andrykowski & Cordova, 1998). Consequently, the ability to accurately qualify the role of avoidance in cancer patients is difficult.

Limitations of this pilot must be considered for future research in this area. First, a larger sample would increase the strength of the study; also, sampling resulted in a heterogenous cancer group that varied in diagnosis time period. Second, the sample consisted of highly self-selected participants who were primarily white middle-upper class, which limits generalizability. The characteristics of self-selected participants, especially those in the comparison group, likewise must be acknowledged. Their interest in serving as controls indicates a potential bias of motivation, which questions objectivity. Also, 51% of the comparison group indicated having an unspecified relative with cancer; this may have influenced comparisons between the two groups. Other limitations are the stability of attachment style under stress and lack of information as to impinging current life stressors that may have impacted responses.

CONCLUSION

Psychosocial variables are just one component of a multifactorial process of disease and recovery (e.g., Wood, 1993, 1995). It has been suggested that attachment may be a psychosocial factor in cancer (Baltrusch and Waltz, 1987). Results from this pilot indicate the need to differentiate avoidance as a coping strategy or as an attachment pattern prior to cancer. While limitations did exist, we believe that this pilot has the potential to stimulate a new line of research into attachment and affective patterns in cancer. Lastly, a broader theoretical psychosocial framework is needed to explain cancer (Greer, 1999). Investigation of attachment processes may aid conceptual integration in such areas as personal relations and affect regulation, the Type C Behavior Pattern, and Wood's Biobehavioral Family Model (BBFM) of psychosocially manifested illness (Wood, 1995).
TABLE 1

Frequencies for Demographic Variables by Group

                                Cancer Group        No Cancer Group

Demographics                 Frequency   Percent   Frequency   Percent

Religion
  Catholic                       8        15.4        11        21.1
  Protestant                    39        75.0        30        57.7
  Other                          5         9.6        11        21.1
Ethnicity
  White                         51        98.1        46        88.5
  Mexican American               1         1.9         4         7.7
  African American               0         0.0         2         3.8
Marital Status
  Married                       43        82.7        36        69.2
  Other                          9        17.3        16        30.8
Education
  High School                   19        36.5        16        30.8
  Tech/Vocational                8        15.4         4         7.7
  College                       15        28.8        15        28.8
  Masters                        7        13.5        11        21.1
  Doctorate                      3         5.8         6        11.5
Income
  $10,000-$24,999                8        15.4         9        17.3
  $25,000-$49,999               20        38.5        21        40.4
  $50,000 or more               24        46.1        22        42.3
Family History of Cancer *
  No                            14        26.9        25        48.1
  Yes                           38        73.1        27        51.9
Work Status **
  Not Working                   18        34.6         9        17.3
  Part-time                     13        25.0         7        13.5
  Full-time                     21        40.4        36        69.2

* p<.05

** p<.01
TABLE 2

Means and Standard Deviations for Dependent Variables by Group

                          Cancer Group      No Cancer Group

Variable                   M       SD          M       SD

Avoidant Attachment *    32.71     9.9       27.00     9.34
Emotional Control **     57.63    11.66      44.98    10.93

* f(1,102)=9.15, p<.01

** f(1,102)=32.57, p<.001


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Anna M. Tacon, Ph.D., Assistant Professor, Department of Health and Physical Education, and Adjunct Professor of Human Development and Family Studies, Texas Tech University, Box 43001, Lubbock, Texas, 79409; 806-742-2940; Q2TAC@ttacs.ttu.edu.

Yvonne M. Caldera, Ph.D., Associate Professor, Department of Human Development and Family Studies, Texas Tech University, Lubbock Texas.

Nancy J. Bell, Ph.D., Professor, Department of Human Development and Family Studies, Texas Tech University, Lubbock, Texas.
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Author:Tacon, Anna M.; Caldera, Yvonne. M.; Bell, Nancy J.
Publication:Families, Systems & Health
Date:Sep 22, 2001
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